One of the only indispensable reasons for going to meetings is having a chance to discuss best practices and procedures with thought leaders. (Can't get that from remote access or web based learning) I missed a presentation on ulnar artery catheterization and PCI but because Mellissa Walton-Shirley reported on it here I was moved to reach out to the author of the paper on ulnar access Dr R K Gokhroo (made possible through he ACC.2015 app) who graciously agreed to meet with me.
I have been a radial first operator for 7 years but have had little experience with ulnar approach
1. hyperextension of the wrist straightens the ulnar
2. stick the ulnar more distally than we normally stick the between 2 creases that are transverse across the distal wrist
3. palpation alone is adequate - no ultrasound needed
4. as you move more proximally along the palpable ulnar artery the tendon may need to be laterally reflected or displaced to access the ulnar which is significantly deeper
5. More proximally the vessel is difficult to compress and has higher issues with gaining hemostasis
6. Infiltrate with 1 -2 ml of lidocaine - important to give it on the radial side of the ulnar artery to avoid infiltration near the ulnar nerve
6. wire access and sheath placement require the same caution and approach as the radial sheath
7. Less spasm with ulnar - he use Diltiazem 2.5 mg, Nitroglycerin 50 mcg and Lidocaine 2% 2 ml (without preservative) as his cocktail. The total of 4 cc diluted with 4 cc of saline and then given rapidly through sheath.
8. Ulnar loops are less frequent (he has seen 2 cases of 1500) and they can be often managed by palpation and physically straightening of the loop in the antecubitum
9. Ulnar occlusion rates are similar to radial occlusion are around 3%
10. He does not use a compressive band - he uses a tightly bound rolled gauze - he does this in part because of cost. It is then supported by a dynaplast dressing. He uses 3 overlapping 1 inch bands placed by the assisted while he maintains hemostasis manually. - he does not incrementally reduce pressure - he does not have any experience with TR band.